What are the National Institute for Health and Care Excellence (NICE) guidelines for lower gastrointestinal (GI) cancer?

From the Guidelines

The management of lower GI cancer should prioritize a multidisciplinary team approach, with surgical resection as the primary treatment for localized disease, and adjuvant chemotherapy regimens such as FOLFOX or CAPOX for stage III and high-risk stage II colon cancer. Although the provided evidence focuses on gastric cancer, the principles of multidisciplinary care and tailored treatment approaches can be applied to lower GI cancers as well 1.

Key Considerations

• Diagnostic pathways should include colonoscopy as the gold standard investigation, with CT colonography as an alternative when colonoscopy is not suitable.
• For rectal cancer, neoadjuvant chemoradiotherapy is recommended for locally advanced disease before surgery.
• Metastatic colorectal cancer treatment options include systemic therapy with combinations of fluoropyrimidines, irinotecan, oxaliplatin, and targeted biological agents like bevacizumab or cetuximab based on RAS mutation status.
• Regular surveillance after treatment is crucial, including carcinoembryonic antigen (CEA) testing, CT scans, and colonoscopy at specific intervals for at least 5 years.

Treatment Approaches

• Surgical resection is the primary treatment for localized disease, with adjuvant chemotherapy regimens such as FOLFOX or CAPOX for stage III and high-risk stage II colon cancer.
• Targeted therapies, such as trastuzumab plus chemotherapy for HER2 overexpression–positive tumors, and nivolumab combined with chemotherapy for tumors with PD-L1 expression levels, may be considered in the treatment of advanced gastric cancer, but their application in lower GI cancer should be based on specific clinical guidelines and evidence 1.
• Multidisciplinary team management is essential for the management of patients with lower GI cancer, ensuring that patients receive comprehensive and coordinated care.

From the Research

Lower GI Cancer NICE Guidelines

• The National Institute for Health and Care Excellence (NICE) provides guidelines for the diagnosis and management of lower GI cancer, including colorectal cancer 2, 3, 4, 5, 6.
• Diagnostic methods for lower GI cancer include computed tomography (CT) colonography, magnetic resonance (MR) colonography, and positron emission tomography (PET)/CT colonography 3, 4, 5, 6.
• The diagnostic value of MR colonography versus CT colonography for colorectal cancer has been compared in several studies, with results showing that both methods have high diagnostic accuracy 2, 5.
• CT colonography is superior to MR colonography in detecting calcified metastases, while MR colonography is more accurate than CT for evaluating liver metastases 4.
• PET/CT colonography is valuable in evaluating extra-colonic and hepatic disease, but there is no definite evidence to support its routine clinical use 4.

Diagnostic Methods

• CT colonography:
  • Provides important information for preoperative assessment of T staging 4.
  • Superior to detect calcified metastases 4.
• MR colonography:
  • More accurate than CT for evaluating liver metastases 4.
  • Has high diagnostic accuracy for colorectal cancer 2, 5.
• PET/CT colonography:
  • Valuable in evaluating extra-colonic and hepatic disease 4.
  • Useful for obstructing colorectal cancers that cannot be traversed colonoscopically 4.

Comparison of Diagnostic Methods

• A systematic review and meta-analysis compared the diagnostic value of MR colonography versus CT colonography for colorectal cancer, finding that both methods have high diagnostic accuracy 5.
• Another study compared CT colonography versus colonoscopy for the diagnosis of colorectal cancer, finding that CT colonography is an option for CRC screening in asymptomatic patients, but is inferior to colonoscopy in detecting advanced colorectal neoplasia 6.